Outcome of acute limb ischemia in cancer patients

Abstract

The optimal management strategy for acute limb ischemia (ALI) in patients with a concomitant malignancy is not well established. A very high mortality rate (83-100%) at 1 year has been reported in those who are treated surgically. Accordingly, a conservative management approach has been suggested as the main therapeutic modality. Our aim was to evaluate the survival outcomes of cancer patients treated for ALI at our cancer center. Cancer patients treated for ALI at the MD Anderson Cancer Center from 2001 to 2011 were included in this study. Overall survival and amputation-free survival rates were calculated. A total of 74 cancer patients with concomitant ALI were included in the study. Surgery was the most common therapy (36 patients; 49%). Percutaneous catheter-based interventions were used in 21 patients (28%). Eighteen patients (24%) received anticoagulation therapy only, and six patients (8%) received no therapy. The 30-day, 6-month, and 1-year overall survival rates were 80% (95% confidence interval [CI], 69% to 87%), 59% (95% CI, 47% to 69%), and 48% (95% CI, 36% to 59%), respectively. Eight patients (11%) underwent amputation. The 1-year amputation-free survival rate was 47% (95% CI, 35% to 58%). In conclusion, we did not find an invasive approach for the treatment of ALI in cancer patients to be associated with the very high mortality rates previously reported. In our opinion, the indications for surgery or catheter-based intervention in these patients should not differ from patients without cancer.

Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia

“…31 Decisions about the management of patients with malignancy should be individualised with the help of oncologists, as active treatment in selected patients can yield good results both from treatment of the leg and the cancer. 32,33 In a prospective study from Denmark with 26 years of follow up, patients with ALI and a newly diagnosed cancer had a higher risk of amputation than similar patients without cancer (hazard ratio [HR] 0.09 vs. 0.06), and patients with cancer also had a higher mortality rate (HR 0.67 vs. 0.37). 34 1.6.2.…”

“…For patients with acute limb ischaemia and underlying malignant disease, active revascularisation in selected patients should be considered, as the immediate postoperative outcome is comparable to patients without malignancy. 32 Tsang et al (2011), 33 Morris-Stiff and Lewis (2010), 31 Nicolajsen et al (2015) 34 clinical practice all six signs are rarely encountered, unless there is a severe ALI in a patient with otherwise normal arteries. Detection of peripheral pulses is enhanced by determination of the ABI using hand held Doppler.…”

Recurrent Arterial Thrombosis as a Presenting Feature of a Variant M3-Acute Promyelocytic Leukemia

“…Degree of limb viability and associated co-morbidities greatly influence the decision whether to manage these patients operatively or non-operatively. No randomized studies are available due to the rarity of this presentation, however experience from the limited number of cases reported ( Table 1 ) and from studies involving patients with solid malignancies presenting with ALI, may guide decision making [ 4 , 41 ]. A conservative management approach has been advocated by some based on studies showing poor outcomes with post-operative mortality as high as 80%–100% when malignancy associated ALI is treated surgically [ 42 , 43 ].…”

“…A conservative management approach has been advocated by some based on studies showing poor outcomes with post-operative mortality as high as 80%–100% when malignancy associated ALI is treated surgically [ 42 , 43 ]. In contrast, recent retrospective studies have favored an early surgery-based limb salvage approach in malignancy associated ALI [ 4 , 41 ]. Mouhayar et al [ 41 ] reported a 47% amputation free survival in cancer patients with ALI when treated surgically.…”

“…In contrast, recent retrospective studies have favored an early surgery-based limb salvage approach in malignancy associated ALI [ 4 , 41 ]. Mouhayar et al [ 41 ] reported a 47% amputation free survival in cancer patients with ALI when treated surgically. Similarly, Tsang et al [ 4 ] also reported a one-year survival of 44% and a 37% limb-loss rate favoring early operative limb salvage.…”